Is It Just a Murmur? | Part 1

This is Part 1 of a three-part Patient Case Quiz.
Click to access: Part 1 | Part 2 | Part 3

A previously heathy 9-month-old infant was referred to the Pediatric Cardiology Clinic for a newly recognized heart murmur. On physical exam, she was a well-nourished, happy looking, playful child with normal growth and developmental milestones. A grade 2/6 continuous murmur was auscultated along the right sternal border which radiated to the entire precordium but not posteriorly. The murmur persisted despite neck motion and positional changes. There were no other pertinent physical examination findings. Her electrocardiogram is shown.

Figure 1

What is the best next step in the management of this child?

A. This is an innocent murmur with non-specific ECG findings. No cardiology follow-up is necessary.

B. The murmur and ECG are concerning. Obtain an Echocardiogram.

C. Refer the child for trans-catheter closure of a patent ductus arteriosus.

Show Answer

The correct answer is: B. The murmur and ECG are concerning. Obtain an Echocardiogram.

This child has a pathologic continuous murmur that persists despite neck motion or positional changes. There is possible left ventricular hypertrophy on ECG based on voltage criteria. Although a patent ductus arteriosus is in the differential, the physical exam findings are not consistent with this diagnosis. Even if it were, its diagnosis would first need to be confirmed before a referral for trans-catheter occlusion is made. An echocardiogram is therefore the next best step in the child's management.

This was Part 1 of a three-part Patient Case Quiz.
Click to access: Part 1 | Part 2 | Part 3